Happiness worksheets
Summary
SOAP notes are a standard healthcare documentation format and essential for mental health clinicians to master.
Reviewing SOAP note examples helps clinicians understand how to organize clinical findings, support insurance reimbursements, and communicate effectively with collaborating providers.
The five therapy SOAP note examples in this article cover Generalized Anxiety Disorder, Major Depressive Disorder, Acute Stress Disorder, Adjustment disorder, and Post-fracture recovery to illustrate real-world documentation across common diagnoses.
Using a practice management platform like SimplePractice gives clinicians instant access to built-in templates, eliminating the need to search for therapy SOAP note examples between sessions.
The SOAP note has become one of the most widely used formats of documentation across multiple sectors of healthcare. It’s common to see specific SOAP note examples for all types of clinicians and health professionals—including SOAP notes for occupational therapy, SOAP notes for physical therapists, as well as SOAP notes for medical doctors and for pharmacists.
Wondering how to write a SOAP note? Looking for therapy SOAP note examples? We’ll walk through the full framework and share some concrete SOAP note examples you can learn from.
Given the usefulness of the SOAP note format and its widespread adoption, it’s essential for mental health clinicians to understand how to interpret and write SOAP notes.
SOAP notes for therapy were designed with a clear purpose: to give treating providers an organized space to record clinical analysis, establish a shared language for communication between collaborating providers, and create a uniform template to store information for later referrers.
Quality therapy SOAP notes can help mental health clinicians to clearly organize their clinical determinations, ensure consistent insurance payouts for their practice and clearly communicate with other collaborating healthcare providers.
This article includes SOAP note examples to help you better understand how to write SOAP notes. Use these real examples as a benchmark, compare against your own notes, or adapt them for your specialty
SOAP note format
When examining therapy SOAP note examples, it’s of primary importance to understand what information each section is designed to capture. Before you read through the sample SOAP notes, review the standard framework and evaluate the quality of your own documentation.
S = subjective
This section focuses on the client’s experiences, views, and emotions from their perspective. It includes the client's chief complaint, the presenting problem, and reported history.
The chief complaint or presenting problem sets the focus for the rest of the documentation, as the majority of the note will typically connect to the core presenting problems.
As shown in the SOAP note examples, relevant direct quotes from the client also belong here as well, since they can help to effectively capture the client’s current state in their own words.
O = objective
This section centers on facts and observable evidence.Descriptive clinical observation and standardized assessment are the priority.
The clinician should focus on mental status measures, observable behaviors, assessment results, and related clinical or medical reports. Any risk assessment would also be included in the findings.
A = assessment
This section applies clinical judgment and analysis to synthesize the Subjective and Objective sections. It’s where the clinician's expertise really comes through, as they’re interpreting the subjective reports of the client, the objective data, and the note determinations related to clinical themes or DSM criteria.
Strong SOAP note examples show that the Assessment is not a recap of the S & O sections, but rather a synthesis that reflects a deeper understanding of the client as revealed during that specific therapy session.
P = plan
In light of the observations and interpretations above, this section outlines specific next steps that will help move clients toward their goals.
It can also include a summary of client progress towards their determined objectives. Any specific adjustments to the treatment plan and near-term targets should be noted as well.
5 helpful SOAP note examples
Whether you're new to clinical documentation or just looking for a quick reference, these therapy SOAP note examples walk you through the SOAP format across a range of common presenting concerns.
All client names, details, and clinical scenarios are entirely fictional and created solely for educational purposes. They do not represent real clients, clinicians, or clinical events.
#1 - Therapy SOAP note example (Generalized Anxiety Disorder)
This therapy SOAP note example documents a session with a client presenting with severe anxiety symptoms. It illustrates how to capture subjective distress, observable behavioral cues, standardized assessment scoring (GAD-7), and a phased treatment plan building toward CBT.
Subjective
Client reported ongoing worry and anticipatory anxiety. They stated "It is hard for me to get excited to go anywhere because I'm always expecting the worst." They also noted extreme restlessness, muscle tension, and an average of 3-4 hours of sleep per night.
Objective
Client's speech was rapid and rambling. Their thought processes were tangential. They frequently avoided discussing their anxiety by diverting to unrelated topics of discussion. They were fidgety throughout the session. Their mood was anxious with congruent affect. They denied any SI/HI or psychosis. They were oriented x 4. Writer conducted the GAD-7 assessment with the client and reviewed the severe score result of 18 with them.
Assessment
Client continues to experience severe symptoms congruent with their Generalized Anxiety Disorder diagnosis. Their frequent rumination, hypervigilance, physical distress, and worry is disruptive to their self care, social life, and occupation. Writer will continue to assess for the possibility of Social Anxiety Disorder given client's previous mention of anxiety-related relational difficulties.
Plan
Client has made minor attempts to implement some of the coping skills discussed with Writer but continues to present with an overall avoidance of deeper intervention for their anxiety. Client has not completed previously agreed-upon homework activities. Writer will continue to build rapport and trust with the client. Writer will provide basic anxiety psychoeducation and teach mindfulness-based relaxation techniques. Writer will introduce the model of CBT to help prepare the client for deeper work on their anxious cognitions, behaviors, and emotions.
#2 - Therapy soap note example (Major Depressive Disorder)
This example note covers a telehealth session with a client experiencing a significant depressive episode. It demonstrates how to document passive suicidal ideation safely, note the client's physical presentation during a virtual visit, and plan early-stage behavioral activation interventions.
Subjective
Client complained of depression and low self-esteem. She endorsed symptoms of low motivation, lack of interest in activities, social isolation, guilt and shame, low mood, loss of appetite, and inability to concentrate. She reported experiencing these symptoms consistently for the past seven months. Client reported "I've never felt this sad before. It feels like I can't get myself motivated to do anything that I used to do."
Objective
Client participated in the video telehealth call from her home. The address is on file. Client presented as disheveled and conducted the appointment while still lying in her bed. She wavered between looking at the camera and lying on her back looking up at the ceiling. Client's speech was slow and halting. Her attention and concentration were within normal limits. She was forthcoming with information and displayed reasonable insight. She denied any HI or psychosis. She reported passive SI last week but denied any current SI, plans, or intent. Writer encouraged her to call 911 or 988 if her SI intensifies and causes concern for her safety. She acknowledged this.
Assessment
The Client meets full criteria for Major Depressive Disorder. Her physical health and relationships are significantly impacted by the severity of her symptoms. The client's mood and activity levels have declined in recent weeks. She has not reported or displayed any signs of mania and thus has not met criteria for Bipolar I or II.
Plan
The Client will benefit from behavioral activation. Writer will provide education about the MDD diagnosis, CBT, and the benefits of behavioral activation for early stages of depression treatment. Writer will work with Client to develop an initial weekly plan of activities.
#3 - Therapy soap note example (Acute Stress Disorder/Trauma)
Written following a recent traumatic car accident, this therapy SOAP note example shows how to document trauma-related symptom clusters, PCL-5 scoring, and the clinical rationale for introducing EMDR—including informed consent language within the plan.
Subjective
Client continues to participate in therapy to address symptoms of acute stress related to a recent car accident. He reported ongoing intrusive symptoms of nightmares, flashbacks, and triggering reminders of the event. He noted avoidance of all driving and avoiding travel by road as much as possible. He stated "I haven't driven again since the accident. I don't know if I will ever be able to drive again." He reported ongoing challenges with hypervigilance, low mood, sleep difficulties, startle response, irritability, social isolation, shame, self-blame, and inability to think positively about the future. Client reported that the symptoms have harmed his relationship with his partner.
Objective
Client was given the PCL-5 assessment and scored a 49, which Writer reviewed with the Client. Client appeared uneasy, uncomfortable, and hypervigilant during session. He frequently shifted positions in his chair, picked at his nails, and anxiously looked out the window. His mood was anxious with congruent affect. His speech, thought processes, and thought content were normal. His insight and judgment were fair. Client was cooperative but was guarded at times when speaking about memories of the accident.
Assessment
Client continues to experience the symptoms of trauma and acute stress. His symptoms directly correlate to the recent car accident that occurred three weeks ago. These symptoms were not present in his life prior to the accident. His relationship issues, emotional difficulties, and avoidance behaviors all started immediately after the accident. He meets full criteria for Acute Stress Disorder and will be reassessed after 1 month post-accident to determine whether he meets criteria for PTSD. He shows good insight and is receptive to therapeutic intervention.
Plan
Client has been receptive to education and the initial stabilizing coping skills taught by Writer. Client has started to utilize the coping skills despite being frustrated by his persisting trauma symptoms. Writer and Client have discussed EMDR therapy and agreed to begin the intervention as soon as possible. Writer has explained risks and benefits of EMDR to client. Writer will begin initial preparation phases of EMDR, while continuing to assess client's stability and capacity to tolerate difficult emotions.
#4 - Therapy SOAP note example (Adjustment Disorder)
This example SOAP note captures a client navigating a major career transition. It's a useful example of distinguishing Adjustment Disorder from major depressive disorder, documenting a mild PHQ-9 score in context, and building an identity-focused treatment plan for a high-functioning client.
Subjective
Client reported ongoing stress and difficulty adjusting to a recent career transition after voluntarily leaving a long-term position to pursue a new professional path. She described feelings of self-doubt, loss of identity, and uncertainty about the future. She stated, "I spent 12 years in that career and now I don't really know who I am without it." She reported mild sleep disruption, difficulty concentrating, reduced appetite, and increased irritability at home with her spouse. She denied any prior history of mental health treatment and described her mood prior to the career change as generally stable and positive.
Objective
Client presented as well-groomed and appropriately dressed. She maintained consistent eye contact and was engaged throughout the session. Her speech was clear and organized. Her thought processes were linear and goal-directed. She was occasionally tearful when discussing her sense of lost identity but was able to compose herself quickly. Her mood was mildly dysthymic with congruent affect. Her insight and judgment were good. She was oriented x 4. She denied any SI/HI, psychosis, or history of mania. Writer administered the PHQ-9 and reviewed the mild score result of 8 with the client.
Assessment
Client is experiencing an adjustment-related response to a significant life transition. Her reported symptoms of low mood, self-doubt, irritability, and disrupted sleep are consistent with Adjustment Disorder with Depressed Mood. Symptoms appear to be directly tied to the career change and were not present prior to this transition. Client does not currently meet full criteria for Major Depressive Disorder. Writer will continue to monitor for any worsening of depressive symptoms. Client demonstrates strong self-awareness and motivation for treatment, which are favorable indicators for progress.
Plan
Client is in the early stages of treatment and is beginning to explore the relationship between her sense of identity and her professional role. Writer will introduce values clarification exercises to help client reconnect with a broader, more stable sense of self beyond her career. Writer will provide psychoeducation on the normative psychological challenges associated with major life transitions. Writer and Client will collaboratively begin to establish short-term goals for the upcoming sessions. Client has agreed to keep a brief daily journal between sessions to track her mood and identify moments of confidence or clarity.
#5 - Occupational therapy SOAP note example (Post-fracture recovery)
Shifting from mental health to physical rehabilitation, this example demonstrates OT-specific documentation including functional assessments, grip strength measurements, compensatory movement patterns, and coordination with the treating physician.
Subjective
Client presented for her weekly occupational therapy session focused on improving daily living skills and return to work functioning following a right wrist fracture sustained six weeks ago. She reported ongoing difficulty with fine motor tasks, stating "I can do some things around the house now, but anything that requires grip or pinching still really frustrates me." She noted challenges with dressing, meal preparation, typing and handwriting. She reported that her inability to return to her job as an administrative assistant has contributed to low mood and a loss of sense of routine and purpose.
Objective
Client presented as alert, cooperative, and motivated. She was dressed appropriately and arrived on time. Writer administered the Jebsen-Taylor Hand Function Test, and client demonstrated significantly reduced speed and accuracy on fine motor subtasks with her right dominant hand compared to normative values. Grip strength was measured at 14 lbs on the right compared to 38 lbs on the left. Client demonstrated compensatory movement patterns during simulated work tasks, including lateral pinch substitution during writing activities. Range of motion in the right wrist remains limited in extension. Client's affect was pleasant but mildly frustrated during challenging tasks.
Assessment
Client continues to present with functional deficits in fine motor coordination, grip strength, and wrist range of motion that are consistent with her post-fracture recovery status. These deficits are directly limiting her ability to perform instrumental activities of daily living (IADLs) and vocational tasks. Client demonstrates strong motivation and adequate insight into her limitations. Compensatory movement patterns observed during the session suggest risk for overuse injury if not addressed. Client is making gradual but measurable progress toward baseline functioning.
Plan
Writer will continue skilled occupational therapy intervention with a focus on progressive strengthening, fine motor retraining, and work simulation activities. Writer will introduce a home exercise program targeting wrist extension and pinch strengthening for client to complete daily between sessions. Writer and client have agreed to incorporate a 15-minute typing simulation task into upcoming sessions to support return-to-work goals. Writer will coordinate with client's physician regarding current range of motion limitations to determine whether further imaging or consultation is warranted. Client's progress will be formally reassessed in two weeks using standardized outcome measures.
Frequently asked questions about SOAP note examples
What does SOAP stand for in therapy notes?
SOAP stands for Subjective, Objective, Assessment, and Plan. Each section captures a distinct layer of the clinical encounter: the client's self-reported experience, the clinician's observable findings, the clinician's clinical interpretation, and the steps planned to move treatment forward.
How long should a therapy SOAP note be?
There's no universal length requirement, but a well-written SOAP note is thorough enough to document the session accurately and brief enough to stay clinically focused. Each section should include only what's relevant to the presenting problem and treatment goals—avoiding unnecessary repetition across sections. See our therapy SOAP note examples for sample text length.
What's the difference between a SOAP note and a progress note?
Both documents record what happened in a session, but they're structured differently. A progress note is typically a narrative summary of the session. A SOAP note organizes that same information into four distinct sections—Subjective, Objective, Assessment, and Plan—making it easier to track clinical reasoning and communicate findings to other providers.
Can I use the same SOAP note template for different diagnoses?
Yes. The SOAP note format is designed to be flexible across diagnoses and clinical presentations. The three therapy SOAP note examples in this article—covering Generalized Anxiety Disorder, Major Depressive Disorder, and Acute Stress Disorder—use the same four-section structure while reflecting the distinct features of each condition.
Do SOAP notes need to be HIPAA-compliant?
Yes. Like all clinical documentation, SOAP notes contain protected health information and must be stored and transmitted in accordance with HIPAA regulations. Using a HIPAA-compliant practice management platform like SimplePractice keeps your notes secure and accessible without requiring separate storage solutions.
How SimplePractice makes SOAP notes even easier
SimplePractice is the HIPAA-compliant practice management software with easy and secure therapy notes, progress notes, SOAP notes, and other note-taking templates built into the platform. Using SimplePractice makes it fast and simple to access your notes and fill them out after each session.
With built in SOAP notes templates in the SimplePractice software, you’ll never find yourself coming up empty when searching for SOAP note examples.
If your EHR doesn’t have built-in SOAP note examples and templates, you can download a SOAP note template to keep on hand, or make your own following the guidelines we provided above.
If you’ve been considering switching to a fully integrated, HIPAA-compliant practice management software, SimplePractice gives you everything you need to streamline your note-taking process. You’ll get more organized and run a fully paperless practice.
You can access SOAP note examples and templates from the robust template library, use the “load previous note” feature to easily update your notes each session, and send follow-up information about your sessions to your clients through the client portal.
Used by over 250,000 clinicians nationwide, SimplePractice is consistently rated as the very best practice management software for therapists, speech-language pathologists, occupational therapists, and other practitioners in the health and wellness industry.
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